Eur J Cardiothorac Surg 2004;26:845-847
© 2004 Elsevier Science NL
Totally endoscopic off-pump bilateral internal thoracic artery bypass grafting
Fadi Farhata*,
Stéphane Auberta,
Pascale Blancb,
Olivier Jegadena
a Department of Cardiovascular Surgery, Unit 31, Professor Jegaden, Hôpital Pradel, Claude Bernard University, INSERM E0226, 28, avenue du doyen Lepine, 69677 Bron Cedex, France
b Department of Anesthesia, Pr. Lehot. Hôpital Pradel, Bron Cedex, France
Received 25 February 2004;
received in revised form 14 April 2004;
accepted 5 May 2004.
* Corresponding author. Tel.: +33-4-72-35-75-28; fax: +33-4-72-35-75-32
e-mail: fadi.farhat{at}chu-lyon.fr
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Abstract
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The introduction of robotic assistance has enabled totally endoscopic closed chest procedures, most often by left internal thoracic artery to left (LITA) anterior descending. Endoscopic stabilizers have made off-pump surgery feasible. We report the first case of a totally endoscopic off-pump bilateral ITA grafting in a 58-year-old patient.
Key Words: Coronary • Robotic • Internal thoracic arteries • Off-pump
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1. Introduction
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Minimally Invasive Cardiac Surgery has evolved over recent years to offer potential benefits over conventional procedures. Different strategies were adopted with variable results when it comes to determine the effects in terms of lessening the invasiveness, based upon two concepts, avoiding cardiopulmonary bypass (CPB) by means of stabilization devices [1,2] and reducing the approach trauma. A left anterior small thoracotomy is well adapted for patients with isolated left anterior descending (LAD) coronary artery disease [3–6]. The introduction of robotic assistance enabled totally endoscopic procedures (TECAB), especially upon the LAD. If this procedure has become a routine technique, only cases of double bypass using both internal thoracic arteries (ITA) with CPB and cardiac arrest has been reported [7,8]. We describe the case of a patient who underwent a totally endoscopic off-pump double bypass using both ITA's.
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2. Case report
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A 58-year-old man without past medical history presented with stable angina (CCS class 3). A coronary angiogram revealed a good left ventricular ejection fraction and a two-vessel disease with a median LAD lesion and a proximal obtuse marginal (OM) stenosis, not accessible to endoluminal angioplasty (Fig. 1)
. After informed consent was obtained, the patient was scheduled for endoscopic revascularization with robotic assistance.
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Fig. 1. Angiogram showing severe stenosis of the left anterior descending and of an obtuse marginal branch.
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After general anesthesia, the patient was intubated with a double lumen tube for single lung ventilation. A trans-esophageal echographic monitoring (TEE) was made through the procedure. An inflatable pillow was placed under the left kidney to elevate the left chest about 30–40 °. Three ports were made on the left anterior axillary line to place the 3D endoscope and the two articulated arms of the daVinciTM surgical system (second, fourth and sixth intercostals spaces, Fig. 2)
. An intra-thoracic inflation of CO2 was made to obtain a pressure of 6 mmHg. In our experience, this pressure was sufficient to create an intrathoracic working space and avoid air tamponade. Selective ventilation was achieved when needed. A 30° thoracoscope was used to harvest the two ITAs, starting with the right one, using electrocautery and endoscopic clips when necessary. After general heparinization (200 µi/kg), both vessels were occluded with bulldog clamps (Scanlan Int., St Paul, Minnesota). The distal ends of the ITAs were clipped and the arteries taken down after preparation.
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Fig. 2. Postoperative view of the different port introduction sites. The three made on the left anterior axillary line were for robotic arms and thoracoscope. The subxyphoid incision allowed the introduction of an endoscopic stabilizer.
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The pericardium was opened and the two target vessels identified. A left subxyphoid port was made to allow the Octopus TETM endoscopic stabilizer (Medtronic Inc.). The LAD was first stabilized and dissected using Pots scissors. The coronary was secured proximally and distally with 4/0 ePTFE sutures, then it was opened over 8 mm. A 2.5 mm coronary shunt was inserted. The RITA was attached to the epicardium prior to anastomose that was made using an ePTFE 8/0 running suture. The stabilizer was then placed around the OM. The same procedure was made with the left internal thoracic artery (LITA), after positioning a 2 mm shunt inside the coronary. No additional stitches were needed. After protamin, surgical hemostase was checked and one chest tube was placed into each pleura through the subxyphoid and the left inferior ports.
The total procedure time was 6 h. The patient was weaned from mechanical ventilation and extubated 6 h postoperatively. Postoperative cardiac enzymes (24 h Troponin t=0.25 ng/ml) as well as ECG and chest X-ray were normal. Total chest drainage was 600 ml. Chest drains were removed on postoperative day (POD) 2. The patient left the intensive care unit on POD 1 and was discharged home on POD 4. Further, postoperative course after 1 month was uneventful and free from angina. A stress test ECG performed at 1 month was clinically and electrically negative (maximum stress level at 210 W), and a radionuclide study (Thallium 201 at rest, MIBI-Tc99m at stress and for ventricular kinetic assessment) did not show residual ischemia in the grafted territories and confirmed the excellent left ventricular function (69%).
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3. Discussion
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If the totally endoscopic LITA to LAD off-pump anastomosis has become a routine technique (over 150 cases worldwide), this is the first reported case of an off-pump double coronary bypass using both internal thoracic arteries to the LAD and a marginal branch.
The video-assisted cardiac procedures upon mitral valve and coronary arteries has been developing over this last decade with the help of novel CPB techniques that can allow cardiac arrest after femoro-femoral access and endovascular aortic clamping [4,9]. This approach remained mandatory in case of multiple vessels grafting, often by the mean of a left anterior small thoracotomy. ITAs were first dissected using 2D thoracoscopes [5]. The anastomoses were then made under direct view through the thoracotomy. The robotic assistance facilitated the ITAs harvesting, and the introduction of new exposure devices (Starfish NSTM) rendered the access to the left ventricle easier. Dogan et al. has reported the first case of a double ITA totally endoscopic bypass grafting upon the LAD and the right coronary artery (RCA) [7]. Yet, this procedure was made after achieving cardiac arrest. In our patient, the endoscopic stabilizer allowed excellent suturing conditions for both target vessels. The access to the LAD is well described. The OM was more challenging. The pericardium was opened transversally 1 cm above the phrenic nerve toward the left appendix. After stabilization, the 30° thoracoscope was turned vision side up to offer an excellent view of the coronary. Thus, shunt insertion and subsequent anastomosis were realized in good conditions. The irrigating catheter, introduced by one of the stabilizer orifices, as well as the use of an intra-coronary shunt, helped to obtain a bloodless operating field. The shunt also provided a suturing security and displayed the surgeon from time limitation. In our experience in single and multiple off-pump vessel surgery, the use of intra-coronary shunts is systematic (ClearviewTM, Medtronic), and has never been reported so far in TECAB. Since the stress test ECG and the radionuclide study were normal 1 month after the surgery, we did not propose a systematic control angiogram.
Comparatively to MIDCAB surgery, multiple vessels TECAB seems to be more time consuming. Nevertheless, this is our first case of a double vessel off-pump TECAB, and time reduction should come along with the multiplication of such procedures. Moreover, such an endoscopic procedure could be greatly facilitated in the future by the development of new distal and proximal automatic anastomotic devices.
The three-vessel disease cases remain the most difficult hurdle to cross. A hybrid therapy based upon ITA grafts for the left lead associated to endoluminal angioplasty using drug eluting stents for RCA lesions seams to be an interesting strategy [10].
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4. Conclusion
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The feasibility of a totally endoscopic off-pump double coronary artery grafting using both internal thoracic arteries is demonstrated in this case. It constitutes a major step in the reduction of invasiveness in cardiac surgery. Even if the reproducibility of such a procedure has to be demonstrated, the ambulatory coronary surgery for multiple vessels is possibly the standard of a near future.
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References
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Abstract
1. Introduction
